Download Current topics in nutrition for the general pediatrician

NUTRITION IN CHILDREN:
WHAT IS HEALTHY EATING?
Carissa Stanton, MD
Clinical Assistant Professor
University of Kansas Pediatrics
Disclosure
•
I have no relevant financial relationships with the
manufacturers(s) of any commercial products(s) and/or
provider of commercial services discussed in this CME
activity
•
I do not intend to discuss an unapproved/investigative
use of a commercial product/device in my presentation.
Objectives
1. Learn what is healthy eating based on the current
clinical evidence
2. Apply nutrition knowledge to patient care during
anticipatory guidance on healthy lifestyle
3. Improve patient’s lifestyle through healthy lifestyle
changes
Overview
• Problem
• Barriers
• What is Healthy eating?
• Portion size
• Nutrient dense
• Meal choices
• Macronutrients
• Micronutrients
• Industrialized food
• Physical activity
• Fruits/vegetables
• Sugar
• Applying to practice
The Problem
• Childhood obesity is one of the most serious public health
problems of the 21st century
• Childhood obesity has tripled in the last 3 decades
• In 2012, approximately 31.8% of children 2-19 were
overweight or obese in US
• Today’s children may have a shorter lifespan than
their parents
Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the
United States, 2011-2012. Journal of the American Medical Association 2014;311(8):806-814
Obesity: Definition
• Obesity
• Condition characterized by the excessive accumulation
and storage of fat in the body
• Body mass index (BMI)
• Kilogram/meter2
• Body weight adjusted for height
• Screening tool that correlates with body fat and health
risks
• Children: Age and gender specific
Kuczmarski RJ, et al. 2000 CDC growth charts for the United States:
Methods and development. Vital Health Stat 2002;246:1-190
Obesity: Definition
• Normal weight BMI 5-84%
• Following own genetic curve
• Overweight BMI 85-94%
• Most will have excess body fat
• Some of high lean body mass
• Obesity BMI >95%
• Almost all have excess body fat
• Severe obesity >99%
• Proposed new category
Barlow SE, et al. Expert committee recommendations regarding the prevention,assessment, and
treatment of child and adolescent overweight and obesity: Summary report.
Pediatrics 2007;120:S164-192
The Problem
• Childhood obesity complications
• Cardiovascular risk factors
• Hypertension
• High cholesterol
• Diabetes
• Bone and joint problems
• Sleep apnea
• Social and psychological
Daniels SR, Arnett DK, Eckel RH, et al. Overweight in children and adolescents: pathophysiology,
consequences, prevention, and treatment. Circulation 2005;111;1999–2002.
The Problem
• Overweight and obese children
often become obese adults1
• Diabetes
• Heart disease and stroke2
• Osteoarthritis
• Cancer3
1. Freedman DS, et al.The relation of childhood BMI to adult adiposity:
the Bogalusa Heart Study. Pediatrics2005;115:22–27
2. Freedman DS, Khan LK, Dietz WH, Srinivasan SA, Berenson GS.
Relationship to coronary heart disease risk factors in adulthood: the
Bogalusa Heart Study. Pediatrics 2001;108:712–718
3. Kushi LH, et al. American Cancer Society guidelines on nutrition
and physical activity for cancer prevention. CA: A Cancer Journal for
Clinicians 2006;56:254–281.
The Problem
• By 2030, 50% of adult Americans will be obese
• 8.5 million more people with diabetes
• 7.3 million more cases of heart disease and stroke
• 670,000 additional cancers
• Economic burden in 2030
• Medical expenditures will increase by $66 billion
annually
Wang Y, et al "Health and economic burden of the projected obesity trends in the USA and the UK"
Lancet 2011; 378:815-25.
The Problem
• Not only excess calories relative to activity
• American diet has become inadequate in crucial nutrients
• Vitamin D, Calcium, Magnesium, fiber
• 30-40% of daily energy of children and adolescents is
consumed as energy-dense but nutrient poor food and
drinks
The Problem
• Chronic disease in children is increasing
• Obesity: 1/3 of children overweight or obese
• Asthma: Doubled since 19801
• ADHD: 7.8% in 2003 to 11.0% in 20112
1. Akinbami LJ, Moorman JE, Garbe PL, Sondik EJ. Status of childhood asthma in the United
States, 1980-2007. Pediatrics. 2009;123:S131-S145
2. Visser, SN. Trends in the parent report of healthcare provider diagnosed Attention deficit
Hyperactivity disorder: United states, 2003-2011. J Am Ac Child Adolescent Psych. 2014; 53:34-46
The Problem
• Genetic vs. environment
• Too rapid for genetic shift
• Environment
• Possible common etiologies
• Increased high calorie/low nutrient processed foods
• Less physical activity
• Increased income inequality
• Adverse childhood events
Perrin JM, Bloom SR, Gortmaker SL. The increase of childhood chronic conditions in the United
States. JAMA 2007;297(24):2755-9
The Solution
Pediatrics 2007;120:S164-192
The Barriers
Nutrition Education
The white paper: Teaching
nutrition and physical
activity in medical school,
training doctors for
prevention-orientated care
http://bipartisanpolicy.org/library/teachingnutrition-and-physical-activity-medicalschool-training-doctors-prevention/
Accessed 2/26/15
The Barriers
• Nutrition and environmental research
• Randomized control studies difficult
• Many variables
• Measurement validity
• Common sense medicine
• Proven not to do harm, proven likely to
do benefit
• The media and consumerism
Todd K, et al. Food intake measurement: problems and approaches. Am J Clin Nutr 2011:37
The Barriers
• Societal values
• Consumerism
• Time and money
• Socioeconomic
Pediatric Nutrition:
What is healthy eating?
What is healthy?: US Government
• Dietary Guidelines Advisory Committee 2015
Low
Healthy diet
Standard American diet
(SAD)
Refined grains, sugar,
red meat
Vegetables, fruit, whole
grains, dairy
Moderate Dairy
High
Vegetables, fruit, whole Refined grains, sugar, red
grains, legumes, nuts
meat
Scientific report of the 2015 Dietary Guidelines Advisory Committee
2015http://www.health.gov/dietaryguidelines/2015-scientific. Accessed 2/27/15-report/
What is healthy?
American Academy of Pediatrics
• Building a “healthy plate”
• Focus on increasing vegetable, fruit, and whole grains
• Appropriate portion size
• Consuming nutrient dense foods
• Reduce intakes of added sugar, sodium, refined grain
products, and trans fat
• Balancing calories with activity
.
R Kleinman and F Greer, Pediatric nutrition 7th Ed. 2013
AAP: Target behaviors
1. Limit portion size
2. Limit consumption of high calorie, low nutrient foods
3. Meal choices
 Balanced macronutrients
 Limit eating out
 Eat meals as family
 Adequate calcium
4. Physical activity
5. Increase fruits and vegetables
6. Limit sugar
Davis MM, et al. Recommendations for the prevention of childhood obesity.
Pediatrics 2007;120:S229-253
1. Portion size
Portion size: Problem
• Portions have doubled or tripled in last 3 decades
• Burden of own industrial food supply success
• Improved to make more food cheaper
• Consumerism
• Companies make more money when consume more
• Make portions bigger
• Make food more addicting with sugar/fat/salt so
consume more
Portion size: Evidence
• Portion size is contributing factor to increasing prevalence
of overweight
• Portion size has been associated positively with BMI1
• Largest determinant of food consumed was amount
served2
1. Huang TT, et al. Energy intake and meal portions: associations with BMI
percentile in US children.Obes Res. 2004;12:1875-1885
2. Mrdjenovic G, Levitsky DA. Children eat what they are served: the imprecise
regulationOf energy intake. Appetite 2005;44:272-282
Portion size: Solution
• Approximately 1 fist size
• Changes with age and size of kid
• i.e toddler portion smaller than adolescent
• Helpful guide when parents say toddler “doesn’t eat
anything”
• Smaller for concentrated things like butter, cheese
• Bigger for green leafy vegetables that have low calorie
• Processed foods read labels for serving size
• Packaged cereal often has portion size of 2/3 cup, when
children eat 1-1.5 cup (around 2 servings)
http://pcdateam.org/nutrition/wp-content/uploads/2014/11/Hands-On-Nutrition-For-Kids.jpg
2. More nutrient to calorie
More nutrients to calorie: Problem
• Highly processed foods
• Lower in nutrients
• Over desirable taste
Overconsumption
• Added
• Trans fats
• Sodium
• Sugar
• Infant and toddler foods
More nutrients to calorie: Problem
Why put sugar and salt in baby food?
To get palate used to processed food (kids literally addicted to processed
food, and then regular whole food doesn’t taste as good)
Added sugar and sodium in early life
Taste preferences
Food choices
Food intake later in life
Cornwal TB, McAlister AR. Alternative thinking about starting points of obesity. Development of child
taste preferences. Appetite 2011;56:428-439
More nutrient to calorie: Evidence
• Eating out of the home
• Evidence shows eating out of home as risk factor for
obesity1
• Associated with greater intake of fried food and sugar
sweetened drinks2
• Higher intake of saturated/trans fat and sugar
• Less intake of nutrients
1. American dietetic association: Childhood overweight evidence analysis Project. 2006.
Available at: www.adaevidencelibrary.com. Accessed June 2007
2. Gillis LJ, Bar-Or O.. Food away from home, sugar-sweetened drink consumption and
juvenile obesity. J Am Coll Nutr. 2003 Dec;22(6):539-45
More nutrients to calorie: Evidence
• Family meals
• Frequency of family dinners associated inversely with
overweight and obesity in 9-14 year olds1
• Parental presence
• Positively associated with adolescent consumption of
fruit, vegetables, and dairy foods2
• Negatively associated with
skipping breakfast
1. Taveras EM, et al. Family dinner and adolescent overweight. Obes Res 2005;13:900-906
2. Videon TM, Manning CK. Influences on adolescent eating patterns: the Importance of family
meals. J Adolesc health. 2003;32:365-373
More nutrient to calorie: Solution
• Eat more family meals in the home
• More nutrient per calorie food
• Closer to nature
3. Meal choices
Source
Pediatric Nutrition 7th Ed. 2013
R Kleinman and F Greer
Meal choices
• Balanced meals
• Micronutrients
• Vitamins, minerals
• Macronutrients
• Percent of energy
• Carbohydrates 4kcal/gm
• 250 gm/2000kcal
• Fats 9 kcal/gm
• 66 gm/2000kcal
• Protein 4kcal/gm
• 75 gm/2000kcal
Meal choices: Carbohydrates
• Carbohydrate
Type
Complex
Simple
Definition
In natural form
with protein, fiber,
nutrients
Humans liked
taste of starch
only so extracted
out starch only
Examples
Potatoes, whole
grains, legumes,
pumpkin
White pasta,
cereal, bread,
processed snacks
Benefit/risk
Has protein, fiber
and nutrients,
slows down
digestion, lower
glycemic index
Straight carb that
has high glycemic
index (stimulates
fast insulin
secretion, then
sugar low)
How to
distinguish
Does not dissolve Melts in mouth bc
in mouth. In
amylase digests
natural
straight into sugar
unprocessed form
• Sugars, starches,
and fiber
• Fruit
• Dairy
• Grains
• Provides energy
• Converted to
glucose
Meal choices: Carbohydrates
• Carbohydrate requirement
• Relatively little is essential in the diet
• Glycerol and amino acids can be converted to
glucose
• Lower limit approximately 100 grams/day
• Based on cerebral glucose utilization
• Recommendation is 50% of energy
• Easy source of energy
Meal choices: Fat
• Fat
• Glycerol with fatty acids
• Roles
• Structural
• Cell membrane
•Every cell in the body needs fat
• Nervous system
•Important for growing children
• Energy
• Dense for infants/toddlers
Meal choices: Fat
• Fat requirement
• Essential fatty acids
• Cannot be synthesized by human body
• Lower limit 15% of energy intake
• Recommendation is 30%
of energy
Meal choices: Fat
• Americans reduced fat intake past 3 decades
• Concern for increased LDL cholesterol
• Consumption of carbohydrates have increased
• Insulin resistance
• Dyslipidemia
• Less satiety
• Self restricting and calorie counting had to start
• Total energy intake 10% greater in children who
consume soft drinks
Daniels SR. Abnormal weight gain and weight management: are carbohydrates the enemy?
Pediatrics 2003;142:225-7
Fat
Unsaturated
Saturated
Polyunsaturated
Omega 3
Fish, flax, etc
Anti-inflammatory
Treat hyperTG
Olive oil,
Mediterranean
diet
Monounsaturated
Omega 6
Vegetable oils,
processed food
Proinflammatory
Trans
Man made: margarine
Proinflammatory, insulin
resistance, central fat
accumulation
•
Dyslipidemia
• High triglycerides
• High LDL
• Low HDL
• Carbohydrates
• Adverse to all dyslipidemia components
•
Saturated fat
LDL
HDL
• Monounsaturated
LDL
• Omega 3
TG HDL
Meal choices: Fat
• Fat
• Current recommendation
• 30% of energy from fat
• Essential fatty acids
• Satiety
• Saturated fat
• Limit to <10% of energy
• Replace with unsaturated fat and not carbohydrates
• Still 22 grams in 2000 kcal/day diet
• Unsaturated fat
• 20% of energy
• Monounsaturated
• Omega 3> Omega 6
• Trans fat
• Avoid
American Heart Association’s Recommendations for healthy children. Available at:
www.heart.org/HEARTORG/GettingHealthy/HealthierKids/Dietary-Recommendations-for-Healthy-Chil
Meal choices
• Protein
• Chains of amino acids
• Animal based
• Plant based
• Role
• Structural
• Functional
• Energy
• Requirement
• Essential amino acids
• Lower limit is 5-10% of energy
• Recommendation is 30%
Meal choices: Vegetarian
• Benefit if balanced
• Low in omega 6 and saturated fat
• High in omega 3, fiber, minerals, phytochemicals
• Improved BMI, CVD, Diabetes, Cancer
• Types
• Pesco: eat fish, dairy and eggs
• Lacto-ovo: eat dairy and eggs
• Lacto: eat dairy
• Ovo: eat eggs
• Vegans: eat only plant derived products
Meal choices: Vegetarian
• Risk if unbalanced
• Protein
• Requirement about 75 grams/day
• 1 chicken breast=22 grams
• 1 handful sunflower seeds=23 grams
• 1 plant source incomplete, so need multiple to get all essential
amino acids
• Iron
• Spinach, beans, tofu
• Vitamin D
• Egg yolk, fortified
• B12
• Eggs, nutritional yeast, fortified
• Fat
• Avocado, nuts, oils
Meal choices: Micronutrients
Micronutrients: Iron
• Iron
• Function
• Hemoglobin
Age
RDA mg/day
0-6 months
0.27
• Anemia
7-12 months
11
• Cognitive deficits
1-3 year
7
4-8 years
10
9-13 years
8
14-18 years
Male 11 Female 15
• Neurodevelopment
• Deficiency
• Recommendation
Baker RD, Greer, FR. Diagnosis and prevention of iron deficiency and iron-deficiency
anemia in infants and young children. Pediatrics 2010; 126(5): 1040-50
Micronutrients:
Iron
• Infants
Food
Iron, mg
• Preterm infants
Baby food green beans 6
1.8
• Breastfed needs additional oz
2mg/kg/day
Baby food, lamb 2.5 oz
1.2
• Term infants
Baby food, chicken 2.5 oz 1.0
• Formula
Baby food, oatmeal cereal
1.6
dry
1
tblsp
• Known fortification
Fortified oatmeal 1 cup
14
• Breastfed > 4 months
Lima beans, ½ cup cooked 2.2
• Need additional
Chicken liver 3 oz
9
1mg/kg/day
• Appropriate iron containing complementary foods or
supplement
• *Can use poly vi sol with iron in BF infants instead of
fortified infant cereal (infants do not need the extra
carbohydrates, can increase obesity risk)
Baker RD, Greer, FR. Diagnosis and prevention of iron deficiency and iron-deficiency
anemia in infants and young children. Pediatrics 2010; 126(5): 1040-50
Micronutrients: Vitamin D
Function
Deficiency effects
Bone health
Rickets, osteoporosis
Immune modulator
Autoimmune, atopy
Cardiovascular health
Hypertension
Growth and regulation
Cancer
Holick MF. Sunlight and vitamin D for bone health and prevention autoimmune diseases, cancers,
and cardiovascular disease. Am J Clin Nutr 2004;80:1678S-1688S
Micronutrients: Vitamin D
• Recommendation
• > 1 year 600 IU/day
• Serum 25 (OH) D > 50 nmol/L
• Sources
• Hard to get recommended amount
• Fatty wild caught fish, pasture raised eggs, fortified foods
• Sun exposure 5-10 minutes
2-3 times per week
• Half life of 2 weeks
• Infants
• Supplement infants with 400 IU/day
• Unless taking 32 ounces formula/day
Abrams SA. Dietary guidelines for calcium and vitamin D: A new era.Pediatrics 2011; 127(3): 566-68
Micronutrients:
Calcium
• Calcium
• Function
• Bone growth/development
• Cofactor: clotting, muscle contraction,neurotransmitter
• Weight regulation
• Deficiency
• Osteoporosis
• Weight
• Recommendation
1 cup dairy milk= 200mg
1 cup plant based milk= 100-200
Abrams SA. Dietary guidelines for calcium and vitamin D: A new era.Pediatrics 2011; 127(3): 566-68
Micronutrient: Calcium
• Dairy
• Practical source of Calcium, Vit D, Potassium in
SAD
• Counteract phosphorus in soda
• Counteract sodium and low nutrients in processed
foods
• Low-fat because added fats in SAD
• But saturated better than trans
• Ideal would be decrease added fats and go back
to whole milk
• New studies that whole is more filling and fat
helps absorption of nutrients
Scharf RJ, Demmer RT, DeBoer MD. Longitudinal evaluation of milk typee consumed and weight
status in preschoolers. Arch Dis Child 2013; 0:1-6
Micronutrients: Magnesium
• Function
• Every organ in the body needs as a cofactor
• Bones
• Energy
• Muscle
• Insulin
R Kleinman and F Greer, Pediatric nutrition 7th Ed. 2013
Micronutrients: Magnesium
• Deficiency
• Acute
• Agitation, anxiety, sleep disorders, abnormal heart
rhythm, muscle spasm, headache
• Chronic
• Constipation
• Chronic illness
• Diabetes
• HTN
• Migraine
• Use
• Asthma
• Migraine
• Constipation
• Requirement
R Kleinman and F Greer, Pediatric nutrition 7th Ed. 2013
Micronutrients: Magnesium
• Source
Single serving bag
cheese crackers
10.1
mgs
McDonald's
hamburger
21.0
mgs
Potato chips - one
ounce
19.6
mgs
Chicken Noodle
Soup
24.2
mgs
Crackers, six,
sandwich style with
cheese filling
10.9
mgs
Magnesium Totals
National Institutes of Health office of dietary supplements fact sheet on magnesium.
https://ods.od.nih.gov/pdf/factsheets/Magnesium-HealthProfessional.pdf. Accessed 3/16/16
85.80
mgs
• Nuts, beans, whole grains, vegetables,
fruit
• SAD diet is deficient
Microbiome
• 10x more bacteria cells than human cells
• Environment affects flora
• Diet
• Breastmilk has prebiotic in it for good bacteria
• SAD lacks bacteria and prebiotics (fiber)
• Antibiotics
• Antibacterial soap and overly sanitized environment
Johnson CL, Versalovic J. The Human Microbiome and its potential importance to pediatrics.
Pediatrics 2012;129(5): 950-960
Microbiome
Symbiotic
Dysbiotic
Nutrition/metabolic
Obesity, DMII
Decrease pathogens
C difficile, yeast
Immune regulation/ intestinal
integrity
Atopy
Inflammation
Microbiome
• Supplement
• Prebiotics: Food for bacteria
• Breastmilk
• Whole grains, fruit, vegetables
• Probiotics: Good bacteria
• Contraindications: central line, major immunodeficiency
• Fermented food
• Multiflora
• Coconut water kefir
• <2 years old: 1-2 ml per day
• 2-5 years old: 2-5 ml per day
• > 5 years old: 5-15 ml per day
Meal choices:
Solution
• 3 balanced
meals per day
• Healthy plate
Meal choices: Solution
Vitamin D
• Supplement all
Iron
• Preterm infants
• Term breastfeeding infants
>4 months old
Calcium
• Adolescents
Magnesium
• Migraines, asthma,
constipation, ADHD
• Epsom salt: skin, muscle
Probiotic
• Antibiotic, atopy, constipation
Omega 3 fat: anti-inflammatory
Integrative Medicine
Industrialized Food Supply
Meal choices: Industrialized food supply
• Another thing that has changed in child’s environment in
past 3 decades
• Produce
• Pesticide
• Herbicide
• Soil depletion
• Less nutrients
• Genetically modified
Horrigan, et al. How sustainable agriculture can address the environmental and human health harms
industrial agriculture. Environmental health 2002;110:445-456
Meal choices: Industrialized food supply
• Livestock
• Grain vs. grass fed
• Omega 6 vs. Omega 3
• Antibiotic
• 40-80% of antibiotics USA
• 75% of that is non-therapeutic
• Hormones
Horrigan, et al. How sustainable agriculture can address the environmental and human health harms
industrial agriculture. Environmental health 2002;110:445-456
Meal choices: Industrialized food supply
• Highly processed foods
• Artificial colors and flavors
• Preservatives
• High fructose corn syrup
• Packaging
• Plastic
• BPA
Meal choices: Organic
• Organic
• Produce
• Not used synthetic pesticides, herbicides, fertilizer,
genetic engineering, ionizing radiation
• Livestock
• Not used antibiotic agents, growth hormones
• Access to outdoors
Meal choices: Organic
• Pesticide
• Primary exposure is diet
• Organic has lower levels
• Urinary pesticide non-detectable organic diet
• Rinsing produce does not decrease exposure
• Few studies, not prospective
• Prenatal exposure associated with lower mental
development, attention problems, smaller head
circumference
• ADHD increased by 55% with 10 fold increase in
urinary organophosphate
Forman J, et al. Organic Foods: Health and environmental advantages and disadvantages.
Pediatrics. 2012 Nov;130(5): e1406-13
Meal choices: Organic
• Hormone
• Sex steroids
• Theorized to play role in earlier puberty and risk
breast cancer
• No clear studies
• Also environmental endocrine disruptors
• Antibiotic
• Promotes drug resistant
organisms that can spread
in food chain
Meal choices: Organic
• Nutrition
• Higher vitamin C, phosphorus, phenols
• Environment
• Organic farms use less energy and less waste
• Soil higher quality
• Comparable production
• Cost
• Only adverse
• But we spend less income on food
• Up to 40% food wasted
Meal choices: Organic
• Conclusion
• Benefit to cost ratio
• As close to nature as possible
• Environmental working group
www.ewg.org
Dirty dozen (produce with most pesticides to avoid)
Clean 15 (produce with less pesticides if can’t buy all
organic)
Meal choices: Industrialized food supply
• Solution
• Local, small farms
• Urban gardening
• Don’t waste food
• Make priority again
• Organic when possible
4: Physical activity
Physical activity: Problem
• Energy imbalance
• Balance between energy intake and expenditure
• Expenditure
• Basal metabolic rate
• Thermogenesis
• Physical activity
Physical activity: Problem
• Less activity
• Daily PE classes decreased from 42% in 1991 to 32%
in 2001
• Active transportation decreased by 37% from 1977 to
1995
• More inactivity
• Screen time exceeded 2 hours/day in 43% of US high
school students
Marshall SJ, et all. A descriptive epidemiology of screen-based media use In youth. J
Adolesc. 2006;29:333-349
Lowry R, et al. Television viewing and its associations with overweight,Sedetary lifestyle, and
insufficient consumption of fruits and vegetables.J Sch Health. 2002;72:413-421
Physical activity: Evidence & Solution
• At least 60 minutes of moderate to vigorous activity
per day
• Comprehensive review 2005
• Supervised programs of 30-45 minute per day reduction
in adiposity among obese children
• Panel of reviewers recommend 60 minutes of typically
intermittent and unsupervised activity per day
Strong WB et al. Evidence based physical activity for school-age youth.
J Pediatr. 2005;146:732-737
Physical activity: Evidence & Solution
• Less than 2 hours of screen time
• 1999 Youth Risk Behavior Survey
• 15,349 US high school students
• >2 hours of television per day associated with
overweight
Lowry R, et al. Television viewing and its associations with overweight, Sedetary lifestyle, and
insufficient consumption of fruits and vegetables. J Sch Health. 2002;72:413-421
Physical Activity
• Caution:
• Can’t just increase activity
• Average American child consumes 90 grams of sugar
per day
• 385 calories
• Would have to walk for 1.5 hours or jog for 45 minutes
to burn that off
• Obese people sometimes get false stigma of
being lazy, when the major problem is eating
hidden sugar
5. Vegetables and fruit
Vegetables and fruit: Problem
• Most likely food group to be consumed in inadequate
amounts in children
• Average American child eats only 2 servings per day
• Includes iceberg lettuce, french fries, and juice
• Literally the healthiest food, but eaten the least
• Most nutrient per calorie
Baranowski T, et al. Patterns in children’s fruit and vegetable consumption by Meal and day of the
week. J Am Coll Nutr. 1997;16:216-223
Vegetables and fruits: Solution
• At least 5 vegetables and fruits per day
• 3 vegetables
• Lunch, snack, dinner
• 2 fruit
• Breakfast, snack
• Juice
• Less fiber with the sugar
• Recommendation is less than 6 oz/day
6. Limit sugar
Sugar: Problem
• Added sugar
• “Empty calories” without nutrition
• Makes foods more desirable
• Taste
• Dopamine release
• Insulin release
• Causes sugar high and low
• Consistent with addiction
• Not sugar naturally in whole fruit
• Has nutrients
• Has fiber which slows down absorption
• Average American consumes added sugar
• 22 teaspoons=90 grams=360 calories per day
Sugar: Problem
• Unhealthy in high amounts
• Hyper-insulinemia
• Increased adiposity
• Dyslipidemia
• Hypertension
• Reduced nutrients
• Inflammation
• Cancer
• Cancer cells need glucose
• Test for cancer with PET scan radiolabeled glucose
• Cardiovascular mortality
adults.
Sugar: Solution
• American Heart Association Recommendation for children
• Maximum 24 grams (6 teaspoons) of added sugar per
day
• Above this increase heart disease risks (HTN,
diabetes II)
• 4 grams=1 teaspoon
• 24 grams=6 teaspoons
Vos MB, et al. Added Sugars and Cardiovascular Disease Risk in Children.
Circulation 2016;134:1-18
How to apply to practice
The fight for healthy kids
Obesity prevention and treatment is:
• Identification of target health behaviors
• Influencing families to change behaviors despite
habits, culture, and environment that promote less
physical activity and more energy intake
• To achieve healthy body weight
• To improve long term health through permanent healthy
lifestyle habits
Holt K, et al. Bright futures: Nutrition 3rd ed. 2011
How to fight
• Motivational interviewing
• Stage of change
• Cognitive behavioral technique
• Set goals
• Monitor behaviors for change
• Positive reinforcement
• Reinforce goals, not weight change
• Do not reward with food
• Expect imperfect adherence
• Teamwork problem solve barriers
• Logistics
Barlow SE, et al. Expert committee recommendations regarding the prevention,
assessment, nd treatment of child and adolescent overweight and obesity:
Summary report. Pediatrics 2007;120:S164-192
Clinic Process
• Identification
• Plot BMI every visit >2 yr
• Flag charts: Problem list
• Screen: Healthy habits questionnaire
• Assessment
• History
• PE
• Labs
• Prevention
• Universal message
• Handouts, posters, anticipatory guidance
• Treatment
• Stage I: PCP every 1-2 months for 6 months
• Stage II&III: refer to dietitian, therapist, tertiary care center
Memorable saying:
Target behaviors
1. Portion:
1 fist size of 1 food
2. More nutrient per less calorie
Close 2 nature
3. Meal choices:
3 balanced meals per day
4. Physical activity:
Good 4 your body
5. Vegetables and fruit:
5 fruits and vegetables
6. Sugar:
Choose foods with less than
6 grams of added sugar
Logistics
• Breakfast
• Oatmeal, fruit, egg
• Snack
• Trail mix
• Lunch
• Whole grain wrap with avocado, turkey,
cheese, spinach
• Snack
• Veggie and fruit with peanut butter
• Dinner
• Chicken vegetable stir fry
with brown rice
Local resources
• www.eatlocalkc.net
find your local farmer's market and identify local markets that accept SNAP
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www.beansandgreens.org
Contact: Gayla Brockman, Phone# 816-753-0606
brings together local farmers and low-income shoppers. Use your SNAP Program toward healthy local food
www.kcfoodcircle.org
Phone#: 913-620-8427, E-mail: [email protected]
Connects you with local organic & free-range food, community supported agriculture (CSA), and farmer's markets
www.cultivatekc.org
Phone#: 913-831-2444
Go to Community Resources link to find information about nutrition and growing food solutions for the community and
residents
www.facebook.com/ffckc
Fresh Food Corridor
Phone#: 816-226-8246, E-mail: [email protected]
Lets you know who provides fresh produce, meat and dairy products to east Kansas City neighborhoods.
www.rosedale.org
Rosedale Healthy Kids & Farmer's Market Phone#: 813-677-5097, E-mail: [email protected]
Promotes healthy kids through healthy food access and physical activity in Rosedale community
Take home message
• Unhealthy lifestyle is #1 problem facing American children
• Should be #1 priority
• Education on the issue and nutrition
• Limit highly processed foods: Close to nature!
• Less than 24 grams added sugar per day
• Most high yield is to stop drinking sugar
• My rule: Water and white milk only, anything else to drink is
a treat once a week!
• Balanced meals at home with family
Thank you
• My family
• Anna Esparham, MD
• Monica Arango, MD
• Joy Weydert, MD
• Stephen Lauer, PhD, MD
• Ann Davis, PhD, MPH, ABPP
• Abby Lowe, RD
• Eva Chevreaux ARNP-NP
Contact:
[email protected]